Post-traumatic stress disorder

Post-Traumatic Stress Disorder (PTSD) is a psychologicaldisorder
that rears its ugly head after someone experiences a very stressful event
or a
life-threatening event. Some of these events might be military combat,
natural disasters, terrorist incidents, serious accidents, or violent personal
assaults. These experiences can be relived through nightmares or
flashbacks. Patients with PTSD may experience trouble sleeping or feel
detached or estranged from others. Symptoms such as these can be so severe
and last so long that it can significantly impair their daily lives.
Marked biological and psychological problems are apparent in PTSD patients.

This is not a new disorder. Symptoms have been documented as far back
as to the Civil War. There are about 30 percent of men and women from war
zones that have experienced PTSD. Some of that percentage includes World
War I, World War II, Korean War, Vietnam and Gulf Warveterans. Also
Holocaust Survivors have experienced Post-Traumatic Stress Disorder.

PTSD does not only occur in war veterans or men and women in the military.
It also occurs in men and women who have experienced such traumatic events
as:

There is treatment for PTSD. It varies in the forms of psychotherapy
and medication therapy. There is no definitive treatment and no cure.
However, some treatments have proven to be quite promising in alleviating the
symptoms of this disorder. Treatments that have had much success are:

Pharmacotherapy (medication): currently there is no
definitive drug that has emerged as the perfect treatment for PTSD, but some
medications relieve the symptoms of stress, depression and panic in many
patients.

Note: I am only in partial agreement with the official viewpoints on this matter, but present them in the name of completeness. To be balanced, I have included both the professional views and the view from where I stand as someone who lived with what professionals consider severe PTSD for a long time.

Official views on PTSD

Post-traumatic stress disorder (PTSD) is the current psychiatric term for a specific set of long-term responses to a traumatic situation: Involuntary re-experiencing of the events, avoidance of anything related to the events, numbing of emotions, and an increase in physical arousal. It is still not known why this occurs in some people and not others.

The extremeness of the event and the level of participation in the event necessary to evoke this response have been controversial since the concept of PTSD was introduced. At one end of things, some professionals have held that only a life-threatening event experienced directly by the individual in question can truly provoke this response. Others have argued that it is the perceived level of threat that is important, and that a person can develop PTSD from witnessing an event. Current criteria allow for both possibilities.

Re-experiencing the events in question can take the form of anything from the inability to get ideas out of one's head, to full-immersion flashbacks that make a person feel exactly as if it is still happening. These things often happen more in response to a trigger -- something that reminds a person of some aspect of the event. For instance, a combat veteran may hear fireworks and react as if the noises come from shooting or bombing. They can also be more intense around the anniversary of the event. Flashbacks are probably the most famous aspect of PTSD, but reactions can be much more subtle or take the form of panic attacks or nightmares.

The unpleasantness and intensity of re-experiencing the events can cause a person to avoid anything they perceive as related to the event. A rape survivor may avoid the street or building in which he or she was raped, as well as any thoughts or emotions that seem remotely connected to it. The person can also become so disconnected from their emotions that they become fairly numb while not re-experiencing the event.

A person with PTSD can be wary, aroused, or jumpy. They may always be on alert, and may overreact to what would otherwise be insignificant stimuli. A honking car horn, while not necessarily arousing memories of the event, may cause a previously sedate person to visibly jump and scream.

recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: in young children, repetitive play may occur in which themes or aspects of the trauma are expressed.

acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur upon awakening or when intoxicated). Note: in children, trauma-specific reenactment may occur.

E. Duration of the disturbance (symptoms in B, C, and D) is more than one month.

F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The ICD-10 contains a similar description, but only requires the presence of a traumatic event and intrusive recollections for diagnosis. The rest of the symptoms, while described, are viewed as nonessential.

People with PTSD have a higher rate of substance abuse, depression, and anxiety. They also have a higher rate of physical health problems, although the exact cause for that higher rate is not known. Health problems could be caused by behavior like substance abuse, by the physiological strain of remaining hypervigilant for years on end, by stress-related chemicals in the body, or various other factors that have not yet been uncovered.

Official views on Complex PTSD

Some professionals have noticed an apparent difference in the way people react to prolonged trauma, especially in situations where the person's entire life is being controlled by another person. Examples might include prisoners of war, people who have been institutionalized, people in long-term abusive relationships, concentration camp survivors, and members of destructive cults. While the idea of a separate diagnosis remains controversial, it has been described alternately as DES-NOS (Disorder of Extreme Stress, Not Otherwise Specified), Chronic Trauma Syndrome, Personality Change from Catastrophic Experience, Post-Traumatic Character Disorder, and Complex PTSD. Some professionals prefer to diagnose PTSD and tack on other diagnostic labels (such as personality or somatization disorders) as necessary.

The essential difference, according to those who believe in it, is that complex PTSD produces deeper, broader, and longer-lasting changes in a person's personality, relationships with other people, and ways of reacting to their surroundings. For instance, a person with complex PTSD might develop a strong attachment to the perpetrator of abuse toward them.

If the most stereotypical example of PTSD is the Vietnam veteran who thinks the war is still going on, the most stereotypical example of complex PTSD might be the battered wife who returns to her husband no matter how much he beats her and seems to almost seek out abusive relationships. People who don't understand may ridicule her as stupid and weak, but internally she is reacting to a view of herself and the world that has been completely remolded by the abuse and control over here life that has been going on for so long.

Dr. Judith Herman, who popularized the term complex PTSD in her book Trauma and Recovery, describes a set of working criteria:

1. A history of subjection to totalitarian control over a prolonged period (months to years). Examples include hostages, prisoners of war, concentration-camp survivors, and survivors of some religious cults. Examples also include those subjected to totalitarian systems in sexual and domestic life, including survivors of domestic battering, childhood physical or sexual abuse, and organized sexual exploitation.

Dr. Herman's belief is that this diagnosis will prevent excessive use of other diagnoses (such as borderline personality disorder) and a "blaming the victim" attitude, toward people who have been subjected to long-term trauma. She acknowledges, however, that professionals have not worked out to what extent these criteria, or a separate diagnosis at all, apply.

Official views on treatment

Professional treatment practices vary with the trends in psychiatry, but the most common are medications, individual therapy, and group therapy.

Medications, when used, tend to be antidepressants and sedatives, for the purpose of helping with depression and anxiety. Some research is going into drugs that deal with stress-related chemicals in the body directly.

Individual therapy can take many forms. Cognitive behavioral therapy aims to teach the patient new ways of viewing and approaching life and problems, rather than the old ways, which are presumed to be dysfunctional. Hypnotherapy may be used to uncover memories, although this is highly controversial because of the unreliability of the memories that do get recovered. Another somewhat controversial technique, known as EMDR (Eye Movement Desensitization and Reprocessing), has the patient focus on specific disturbing memories while moving his eyes back and forth, purportedly helping him "reprocess" the memory. Other forms of individual therapy may follow the usual conventions of various forms of psychoanalysis, and may help patients to air their emotions or learn to trust people again.

Some professionals believe that it is imperative to remember and relive the traumatic experience in order to recover. Others disagree, believing that it may even be damaging for people to remember things before they are ready. A recent study has shown that the debriefings given to some people immediately after traumatic events can force a person to think about the event more intensely than otherwise, increasing the risk of long-term reactions.

Group therapy lets the person meet other people who have been through similar things. This can allow him to learn ways of dealing with the world from people who have been there, and to find out how he might look from the outside. It can also be a source of emotional support. There are also numerous self-help and support groups for people with PTSD on the Internet and in real life.

The physiological changes resulting from strain on the body can result in a variety of physical illnesses, which are real and should be treated.

Most people who treat PTSD through therapy will use some combination of the above techniques, rather than just one.

My unofficial, personal, biased views

These views are entangled with me and my past, because that is the nature of how these things work.

I have a piece of paper from my psychiatrist that says I have PTSD, and where most of it came from. To me, the piece of paper is not that important. It gives me insurance against things that could compound the problem, and that is most of its use: to keep me out of the psychiatric system, and to explain the more incomprehensible side of my behavior to professionals.

Post-traumatic stress disorder is, to me, a set of words that describe the ways in which I have contorted myself to adapt to an unremittingly hostile environment that happens to now be in the past. It does not have a life of its own. There is no disease called PTSD in my brain that can be ripped out with the proper therapy. There are only lots of mental and physical survival mechanisms, some of them more useful than others. My only wish is to keep the useful ones and to not need the harmful ones.

Once the situation that brought all of this on was over, I didn't notice it was over. Until recently, talking about flashbacks was an interesting exercise in semantics. It would have been more accurate to say that I had rare and intermittent flashes of the present. I wrote the wrong decade on my personal cheques, and my degree of immersion in the past varied only in how hallucinatory it became: If I physically perceived objects from the past, I called it a flashback, and the rest of the time my thoughts and emotions were in the past while my senses were in the present. I called people in the present by the names of people from the past, and even when I didn't do that I reacted to them as if they were different people. Even since I learned what PTSD was, it hasn't meant I can always tell by logic which sensory perceptions are the past and which are the present. It's that vivid.

I reenacted situations from the past, even when I didn't know I was doing it. Every February, like clockwork, I had an overwhelming urge to kill myself by strangulation or suffocation. It took time to remember that February was the month I had nearly suffocated to death. I'm told I had a habit of embarking on incongruous monologues that seemed to be lifted straight out of a years-dead conversation, and, more worryingly, getting into fights with people that seemed to mirror prior events in which my life was endangered. It's sobering to find yourself on top of your best friend staring them in the face while they hold your fists away from them and ask you, "Do you know who I am?" Especially when you've always been against most violence on principle, and you start wondering if your exception for self-defense applies to hallucinations.

I refused to go to parts of my house that had been deemed off-limits in other settings. I didn't bother going outside because I thought the door was locked. I was afraid of doctors. I heard screaming in my head all the time. I had the same nightmares every night, and often couldn't get out of bed in the morning because I thought I was strapped to it: Someone else had to tell me the straps were being let off one by one, as protocol had been, or else convince me they were not there at all. The world I was living in was like a surreal and constant form of time travel, the present mixing with various parts of the past. They were so entangled that I often looked around for the past in the present, thinking I must be missing something.

I oscillated between feeling nothing at all, and feeling things I had not felt at the time the events I was reacting to were occurring. I had strings of panic attacks so frequently that at times I seemed to run out of whatever chemicals fueled them, but my body kept trying to panic anyway. To top it all off, when I did notice I was not there anymore, I felt guilty for being alive. I'd end up banging my head on a wall just to try to get it to stop, and at one point I contemplated gouging my brain out but couldn't seem to find the tools to do it.

I was fortunate. There were people around me who were willing to patiently show me that the world today was not like the world yesterday. They protected me from the system, while reinforcing the better world I was living in here and now. They did not, as many people did, claim that I was deliberately living in the past, and they did not, as many therapists do, force me to relive it. I was already reliving it every day. The people who helped me the most were ordinary everyday friends who helped show me that this had happened to other people too, I was not going to be judged for it, I did not need to protect myself from the past anymore, and that it was safe and possible to deal with the present.

Without them, I would have been a classic revolving door chronic patient: Entering the system, being traumatized there, leaving, showing I was too crazy to be let out, getting back in, and being traumatized again until the layers were so thick there would be little chance of escape and I would have kept the psychosis label I'd been given for life instead of having it rescinded. That is essentially what had been happening to me until I gained the social resources to avoid the system altogether.

Nonetheless, it took four and a half years before I was able to say I had flashbacks rather than glimpses of the present, and that I was starting to respond to things in ways that made sense more often than not. I went through a February with no flashbacks, and I knew that my life was getting better. Since then, I have come to the conclusion that there is probably no end to this. These events will stick with me forever, as similar events do for anyone. I remember, I always will. But the longer I live my life without all of this, the better I feel, and the less likely my mind is to try to jump back in time. I can sometimes forget for a whole day that these things happened at all. The present is a very nice place.

At the same time, it's not simple. The medical models of PTSD fall short of the reality. This is not a disease that I acquired and am healing from. This is what happens when a person's survival instincts turn against them in a situation they were not built for in the first place. A situation that often has a political and social context. The person this happens to belongs to a society.

Rather than viewing myself as recovering from a disease, therefore, I work politically to build a world in which it is safe for me and others like me to remain in the present. I don't do this for therapy. I do it because it seems like the right thing to do. People's reactions, however bizarre they may become, cannot be separated neatly from our surroundings in the form of a disorder, and the diagnosis of PTSD is one of the clearest examples of this. Both we and our circumstances need to change.

There is a lot of irony in these phonecalls. Not in the content, mind you, but in the fact that I get them and that I get so many of them. The people who should be getting these phonecalls would be very ruffled to know that I am getting them instead, and it is that particular attitude, in part, that ensures that I keep getting them.

This is all getting very abstract. I don't like abstract. There is too much abstraction leading up to these phonecalls. Abstraction from people who refuse to deal with reality, because it would be too difficult or too expensive or leave too large a black mark on careers built on accounting tricks.

I get calls from friends of friends, friends of friends of friends, and so on down the line. Sobbing, drunk, panicky, and combinations of the three. The people who call me very often have never talked to me before, but they all have something in common. They're veterans, and they're at the end of their ropes - on at least one occasion, literally.

Most of them have tried to get help, or worse, have been ordered to get help. "Help" typically consists of being shoved full of antidepressants, or even opiates as an off-label tranquilizer, run through a week of light duty, and then rubberstamped either "FIT FOR DUTY" or "TREATMENT COMPLETE", depending on which big machine still owns them.

On the rare occasion they fall through the cracks and get what they really need, which is someone to talk to, they get some credentialed buffoon who doesn't even realize the depths of their own ignorance. They are shunted off by the buffoon after the mandatory three sessions to a "prescribing therapist" because the buffoons can't understand why suggestions like "avoid caffeine before bedtime" don't quiet the night terrors and panic attacks.

So, my name gets brought up from time to time. "He's been around the block," they say. "He knows what it's like." I know these things are said because they're usually some of the first questions I answer.

I don't have the luxury of screening my calls anymore. When the phone rings, I answer it. Area codes mean nothing. Time of day means nothing. It's in the dark of morning when things are worst. Insomnia piled on alcohol piled on screaming horrors piled on everything else.

Here is how it starts:

"Um, hi. I'm sorry to wake you."

No, it's no problem. Who am I speaking to?

"Uhhh, this is so-and-so. I got your number from a friend who said you might be able to help me."

Sure brother, give me a second to get a cigarette and some coffee. Just one second. Don't hang up. Stay right there. (You would be amazed how long it took me to learn to say this. Too long of a pause and they'll reconsider, feel foolish and troublesome, and hang up.)

"Well, I still have most of my legs. Thought I was gonna lose a nut..."

By the time I've filled in the major details (how many tours, what areas, what units) the coffee is ready and the cigarette is finished. This gives me a sense of how ugly it was for them and it lets them know that I'm hearing them, not just listening and nodding and figuring out from which pamphlet I should be constructing my response.

That I know the right questions to ask is sometimes enough to get them to open up immediately. By the time they call me they're usually pretty fucking desperate, anyway. Look, I'm not educated at all in this field, except the hard way. I operate on intuition, empathy, and the occasional dose of "nobody else is willing to say it because it doesn't align with the goals of this particular organization".

My theory is this: after sometimes years of talking to an endless loop of so-called professionals who treat you like an alien and blame you subtly when their little bag of tricks comes up short, someone who simply accepts your horrors for what they are is enough.

So I listen. Sometimes I talk, but mostly I listen. Sometimes I have to tell them to calm down. Sometimes I have to tell them to stop yelling. A lot of times, I have to let them cry for a while and get them to repeat things after the sobbing has tapered to a bearable level.

After they've told me their end, I usually field questions. "Hey, just one on one, no bullshit, do you sometimes..." and my answer is almost always either a straight yes, or a "Not me personally, but..."

With all of the education and therapy and help that our veterans are supposedly getting, how is it that so many of them can be so relieved to find that their PTSD symptoms are so common? That they aren't the only ones who fly into fits of rage over what should be non-item annoyances? That they aren't the only ones who can't sleep at night, or sleepwalk, or get antsy around heavy traffic? How can the majority of people call me not know that the majority of people who call me have the same exact problems?

The calls takes hours. Hours and hours sometimes. And at the end of it, I tell about 75% of them that they need to get to an AA meeting out in town, not on base. A lot have been through mandatory alcohol abuse programs, or have been to military AA meetings. Bad choices, both of them, because you're not going to do well in a program where you're trying to hide the truth as much as possible because you're afraid of your peers' reaction.

The self medication comes from doubt. When the VA just wants to put you on drug after drug after drug, and won't listen when you tell them things are getting worse, you begin to doubt the medical professionals who aren't fixing a goddamned thing, so you self medicate with booze. See, pills are cheap when you buy them in the quantity that the VA does. Much cheaper to dole out those little yellow bottles full of help than to build a decent program based on human beings helping other human beings.

And it's not as though there are many qualified human beings to begin with. It's hard to take a therapist seriously when you know that his concept of PTSD is what you can read in the DSM, and his concept of war is what you get from blockbuster movies or worse, stuff like that idiot Dave Grossman flogs. Stuff that is draped in intellectualism and the stink of echo chamber nonsense.

Most of the people who call me, if they're still active duty, I tell them they need to go find a chaplain and ask for help in doing the paperwork and hoop-jumping necessary to get the military to pay for them to go to a civilian counselor. Not a psychiatrist, who is just going to diagnose them yet again and dope them to the gills some more, as if the problem can be banished, demon-like, by discovering its name and applying the proper potion. Not a therapist, who is going to talk themselves in circles because it's the only way they can cope with something not in their playbook.

A counselor.

Someone to listen to them and to help them sort out their feelings. Most are resistant. They've tried headshrinkers, and they have been let down. The analogy I often resort to is this:

Imagine you have an M16, an M240, an M9, and a cuckoo clock disassembled, and with all of their parts put into a laundry bag and shaken up. What you understand right now is that none of your weapons work and you don't even know what time it is. You understand that your life is all fucked up and you can't even tell why.

What you are trying to do is reassemble everything using nothing but your tongue, and with a blindfold on. Your first step is to take off the blindfold and realize that your situation is fucked beyond your training, and that you're going to need some help. You're going to need to get all those parts sorted and get the weapons reassembled. Some of your problems, yeah, there's a manual for that. The drinking, the anger, the insomnia, that shit is easy. The parts you don't remember perfectly, you look at the manual and you get to it. You go to AA, you learn to tame your temper, you get your schedule under control.

But that clock, man, have you ever even seen the guts of a cuckoo clock before? No, shit no. And even if you found a manual for that thing, they're all different. That's your feelings. You need someone to help you figure out how you feel, to separate out the different little springs and gears and levers and shit you don't even know the name for, and help you figure out how to get that clock running again. There's no shame in that, you never had training on how to deal with no fucking cuckoo clock. All this stuff gets jumbled up in there so bad that the parts just fall out, and you have to suck it up and realize that if you want to get your house in order, you're going to need to find a decent watchmaker who can tell you what all those parts are.

Yeah, there are jewelers out there who don't know what they're doing, but the solution isn't to decide the clock is irreparably fucked just because one idiot swears that it only needs a new battery. You keep at it, because nobody else is going to do it for you.

Some of them take my advice, and some don't. I'm always very upfront in telling them that they aren't going to hear anything from me they haven't probably heard or thought about for themselves before.

A lot of them call just wanting to vent, to beat on their chests and wail for a while, or to shine a light however feeble into the dark corners. I've lost count of the number of times I've heard "I've never told anybody this before."

Some of them are indeed ready to climb out of the pit - I recently got a six months token and a scrawled "THANKS" in the mail with no return address.

A lot of them are still fighting, and some have given up. A .45 to the noggin or a belt on the coat rack are tough ways to give up, but I suppose it's one way to take back control of a life you feel like you've already lost.

I got a hard one tonight. Real hard. It rips my guts out every single time to hear firsthand how abandoned and alone, even intentionally neglected, someone can feel after they've already been through so much.

If you're reading this and feel like you need to talk, haqiqato @ gmail.com.